Money and Medicine: The Evolution of

National Health Expenditures Thomas

E. Getzen
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 Advance Praise for Money and Medicine

“Global growth in health spending by people and their governments means

more of our money will be headed into the world’s inscrutable health sys-
tems. Getzen’s mastery of the subject across time and space is a gift to eve-
ryone who wants health dollars to achieve value, fairness, and health for all.”
—David Bishai, MD MPH PhD, Professor, Johns Hopkins University

“This book has been a major project for a number of years. I cannot think
of any source documenting the key influences on health expenditure in
more detail, with such a large number of citations. Much of the research
for the book was conducted during the period during which Tom was
establishing the International Health Economics Association (IHEA).
That enduring professional society and this book will be his legacy.”
—Michael Drummond, Professor of Health Economics, University of York
Money and Medicine
 Money and Medicine
The Evolution of National Health Expenditures

Thomas E. Getzen
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Library of Congress Cataloging-​in-​Publication Data

Names: Getzen, Thomas E., author.
Title: Money and medicine : the evolution of national health expenditures /
Thomas E. Getzen.
Description: New York, NY : Oxford University Press, [2023] |
Includes bibliographical references and index.
Identifiers: LCCN 2022027295 (print) | LCCN 2022027296 (ebook) |
ISBN 9780197573266 (hardback) | ISBN 9780197573280 (epub)
Subjects: MESH: Health Expenditures—history | History, Modern 1601- |
Healthcare Financing | Economics, Medical—trends
Classification: LCC RA410.53 (print) | LCC RA410.53 (ebook) | NLM W 74.1
| DDC 338.4/73621—dc23/eng/20220801
LC record available at https://lccn.loc.gov/2022027295
LC ebook record available at https://lccn.loc.gov/2022027296

DOI: 10.1093/​oso/​9780197573266.001.0001

1 3 5 7 9 8 6 4 2
Printed by Integrated Books International, United States of America
 To Karen and J.-​P.
—​we will always have Paris
Contents

List of Tables and Figures  xiii

Preface  xvii
Acknowledgments  xxi

1. Introduction: The Transformation of Medicine  1

2. Hammurabi to Middlemarch, 1750 bce to 1850 ce  10

Historical Review  10
State Medicine, Hospitals, and Public Health  17
Medical Effectiveness and Expenditures from 1800 bce to the 19th Century ce  19
Early Medicine: 3,000-​Year Generalizations  23

3. The Rise of Modern Medicine, 1880–​1975  26

Preconditions  27
Medical Expenditure Trends and Levels  32
Advances in Medical Science  37
Institutional Changes Driven by Technology  45
Financing and Health Insurance  49
Coalescence of National Health Systems and “Postmodern” Medicine
After 1975  53

4. Global and National Market Trends, 1950–​2019  59

Growth Trends for 21 OECD Countries  60
Trends in Emerging Markets and LDCs  73
Convergence?  79

5. Scaling Up  83
Medical Science Scales Up  83
Organizational Scale: From Doctors to Hospitals to Networks  84
Financial Scale: From Patient Fees and Charity to Social Insurance  85
From Commodity to Human Right: Ethical and Moral Scales  86
Political Scales: From Neighborhood to Nation  89
Interacting Scales and the Coalescence of National Health Systems  90
Path Dependence and Timing  92

6. Contracts: Buying and Selling Medical Care  98

What Is a Price?  98
Network Financing and Social Contracts  99
What Makes Medical Transactions Different?  100
“Uncertainty and the Welfare Economics of Medical Care” by K. J. Arrow  103
x Contents

Evolutionary Perspectives: The Adjustment of Medical Institutions  106

Third-​Party Payment and the Changing Nature of Medical Transactions  109

7. United States: A Case Study of Leadership and Excess  118

US Data and Literature Review  119
Historical Trends over the Last 200+​Years  124
Trend Shifts and Regime Changes  141
The Breakdown of Voluntary Financing  143
When and Why Did US National Health Expenditures Become an Outlier?  146
Static Versus Dynamic Efficiency, Global Versus Local Effects  154

8. Aging Populations  162

Expenditures and Population Aging Across Countries  162
Spending on the Elderly Is a Result of Policy, Not Biology  164
Time-​to-​Death and the Marginal Value of Medical Care  167

9. Temporary Fluctuations, Trend Shifts, Lags, and Inertia  171

Decomposing Growth: Population, Inflation, Real GDP per Capita,
Plus “Excess”  171
Lags  172
Smoothing: Short-​or Long-​Run? How Many Years?  177
Employment  183
Unemployment, Longevity, and Mortality Rates  185
A Tale of Two Necessities  186
Expectations  187
Specifying Turning Points and Growth Paths  189

10. Measuring NHE: Accounting, Boundaries, and Budgets  193

Accounting Frameworks for National Health Expenditures  194
Boundaries: Categorical, Temporal, Spatial  200
Scale and Units of Observation  205
Budgets: How Much and Compared to What?  206
What Is “Technological Growth”?  209
Limits to Measurement and Econometric Testing  211

11. Forecasting National Health Expenditures: 2030 to 2130  217

NHE Projections for 2025 to the 2030s  218
Short-​Term Nearcasts Are Different from Long-​Run Forecasts  220
Types of Forecast Modeling  223
Accuracy  225
NHE Forecasting for the Very Long Run: 2050 to 2130  227
Forecasting in the Time of COVID  230

12. Conclusion: Seeing the Growth Curve Bend  234

Micro to Macro: Seeing the Leaves, the Trees, the Forest, and the Ecosystem  234
Seeing the Curve  235
A Budgetary Perspective  237
 Contents xi

National Health Systems  238

Evolution  240
The Nature of Medical Transactions  242

Appendices  245
Appendix A: Data Sources, Documentation, and Extrapolations:
International, 1850–​2019  247
Appendix B: Data Sources, Documentation, and Extrapolations:
United States, 1770–​2020  277
Appendix C: An Economic Exegesis of the Hippocratic Oath  287
Appendix D: Is Sir William Petty’s 1672 Treatise on Taxes the First
Health Economics Paper?  291
References  293
Index  323
Tables and Figures

Tables

1.1 20th-​Century Transformations 3

2.1 Number of Physicians Relative to Population in Renaissance Italy 13
2.2 Consumption of 153 Belgian Families, 1853 21
2.3 Occupations of People in the United Kingdom, 1841–​1891 22
2.4 Occupations of People in the United States, 1850–​1900 23
3.1 World Population and Incomes, 1700 to 2000 29
3.2 UK Medical Shares, 1900 to 1938 36
3.3 Sickness Insurance in Germany, 1885–​1891 51
3.4 Weekly Family Expenditures by UK Social Class, 1938 52
4.1 OECD Health Data, NHE as % of GDP 63
6.1 Weak Versus Strong Licensure 108
6.2 Stages in Nonprofit Financial Reimbursement Cycles 111
7.1 Studies of Trends in US NHE Growth with Spans of 20+​Years 122
7.2 Health Expenditures, GDP, Population, and Employment: United States,
1776–​2016 126
7.3 Consumer Expenditure Surveys, 1909–​1931 128
7.4 CCMC Estimates of Total Expenditures for Medical Care, 1929 129
7.5 US Hospitals: Beds, Days, FTEs, and Cost per Day, 1910–​2015 133
7.6 Spending % by Provider Category, United States, 1910–​2015 135
7.7 Payer Financing %, United States, 1929–​2015 137
7.8 Eras in the Growth of US Health Expenditures 142
8.1 Personal Health Care Spending per Capita by Age Group: United States,
Selected Years 1953–​2014 165
8.2 Allocation of US NHE by Age Group: 1963, 1987, 2014 166
8.3 US Medicare Spending per Month by Age and Years to Death (TTD) 168
9.1 Annualized % increase (CAGR) in NHE Decomposed: OECD 1970–​2000 173
xiv Tables and Figures

9.2 Inflation and Health Employment: Canada, 1972–​1975 174

9.3 Regressions: % Growth in Real Health Expenditures, United States,
1960–​2009 178
10.1 System of Health Accounts (SHA) Framework 198
11.1 Nearcasts Compared to Long-​Run Forecasts 223
A.1a NHE %Share of GDP: OECD 1960–​2017 248
A.1b OECD 1960–​1983 NHE—​GDP—​%Share 253
A.1c OECD 1960–​1987 NHE—​GDP—​%Share 258
A.1d NHE % of GDP: OECD 1960–​2012 267
A.1e Methods Used to Extrapolate, Link, and Compile Table A.1a 270
A.2 International Data on NHE % of GNP 1950–​1975, Selected Countries 271
A.3 NHE % of GNP for 18 Countries, 1960/​1962 272
A.4 Canadian Report on Nine Countries NHE % of GNP from 1953 to 1961 273
A.5 Occupations of People in the United Kingdom, 1841–​1891 273
A.6a Total and Medical Consumption in the United Kingdom, 1900–​1938 273
A.6b Medical Employment and Total Population in the United Kingdom,
1900–​1938 275
B.1 Occupational Data for 11 US Cities, 1772 to 1806 278
B.2 US Census Occupational Data, 1850–​1990 279
B.3 BLS Employment, 1958–​2020 280
B.4 National Health Expenditure Estimates, 1776–​2020 284

Figures

1.1 S-​Curve Growth in Health Share of GDP, 1850 to 2100 3

3.1 US National Institutes of Health Funding, 1938–​2020 42
3.2 Nobel Prize Distribution by Region, 1900 to 2020 43
4.1 Global Comparison of National Populations and Medical Market Size 60
4.2a Median OECD Health Share of GDP, 1950–​2019 61
4.2b Annualized 10-​Year % Growth of OECD Median, 1961–​2019 62
4.3a NHE Share of GDP: France, Germany, Italy, Japan, 1960–​2019 64
4.3b Excess % (Share) Growth Rates: France, Germany, 1960–​2019 64
4.3c Excess % (Share) Growth Rates: Italy, Japan, 1960–​2019 65
4.4a Health Share of GDP: Sweden, Norway, Finland, Denmark 66
4.4b Excess % (Share) Growth Rates: Sweden, Norway, Finland 66
 Tables and Figures xv

4.5a Health Share of GDP: United Kingdom, United States,

Canada, Australia, New Zealand 68
4.5b Excess % (Share) Growth Rates: United Kingdom,
United States 68
4.5c Excess % (Share) Growth Rates: Canada, Australia,
New Zealand 69
4.6 NHE Share of GDP: Netherlands, Belgium, Switzerland,
Austria 70
4.7 NHE Share of GDP: Spain, Portugal, Ireland, Greece 71
4.8 OECD21, G7, and Eu4 Medians Compared 74
4.9 Distribution of Country Health Shares of GDP: 1961,
1995, 2015 75
4.10 NHE Share of GDP: Korea, Turkey, China, India 76
4.11 NHE Share of GDP: Brazil, Colombia, Costa Rica, Mexico 77
4.12 NHE Share of GDP: Hungary, Poland, Estonia, Russia 78
4.13 NHE Share of GDP: Vietnam, Philippines, Thailand,
Indonesia, Pakistan 78
4.14 NHE Share of GDP: Nigeria, Ghana, Kenya, Egypt,
South Africa 79
7.1 Health Share of US GDP, 1776–​2020 119
7.2 % Annualized Growth Rate, 1850–​2020 (15-​Year Moving
Average) 119
7.3 J. R. Seale (1959), “A General Theory of National
Expenditure on Medical Care” 131
7.4 US Health Financing as % of US GDP by Payer, 1900–​2015 137
7.5a Canada and US NHE Shares of GDP, 1950–​2019 148
7.5b Canada and US % Change in Health Shares (10-​Year
Moving Average) 149
8.1a Correlation: NHE Shares Across OECD Countries to
% Population Age 65+​in 1975 163
8.1b Correlation: Growth of NHE Shares to Increases in
% Population Age 65+​from 1975 to 2010 163
8.2 Age Ratio in Medical Expenditures per Capita (Age 65+​):
(Age 0–​64), United States, Selected Years, 1953 to 2014 166
9.1 Annual Growth Rate of NHE by Component, United States,
1960–​2019 172
9.2a Annual Growth in GDP and NHE, Finland, 1980–​2000 175
9.2b and c Regression Scattergrams: NHE × Income Growth, Finland,
1980–​2000 176
xvi Tables and Figures

9.3a and b US Regressions: NHE Relative to Income, 1960–​2016 177

9.4 NHE Annual Growth Compared to Lag Smoothed GDP,
United States, 1960–​2019 179
9.5a Netherlands: 1-​, 3-​, 5-​, and 10-​Year Moving Average,
% Growth in NHE 180
9.5b Netherlands: 10-​, 15-​, and 20-​Year Moving Average,
% Growth in NHE 180
9.6 France and Germany: 10-​Year Moving Average,
NHE % Share Growth 181
9.7 United Kingdom and United States: 10-​Year Moving Average,
NHE % Share Growth 182
9.8 Nordic Countries: 10-​Year Moving Average, NHE % Share Growth 182
9.9 Total and Health Employment, United States, 1995–​2020 183
9.10a Monthly % Change in Employment, United States, 2005–​2020 184
9.10b Annual % Change in Employment, United States, 2005–​2020 184
10.1 Temporal and Spatial Units of Observation 206
Preface

This project began with an exercise created for a doctoral seminar 40 years ago.
I asked students to replicate and extend Joseph Newhouse’s 1977 study that
attributed most international variation in expenditures to per capita income
differences. Although the students moved on with their degrees to academic
posts, I became fixated on the determination of national health expenditures.
My search for data and answers has lasted for decades and taken me around
the world, where I benefitted from the assistance of many colleagues. Total
spending seemed like one of the most important issues in health economics to
me, and still does.
Regressions done with floppy disks on an Apple II showed that income
varied more than spending, that there were anomalies, and that some data
were questionable. Smoothing income over several years provided a better fit.
Examining rates of growth over time indicated that there were lags. Growth in
spending was affected by income and inflation in prior years, yet current year
changes were almost irrelevant. These lags provided a satisfying explanation
for why business cycles were so hard to observe in health spending data, and
could also be exploited to forecast future expenditure growth. These became
the subjects for a series of articles.
Claims that aging caused rapid increases in medical spending suggested
testing this hypothesis with international data. Comparisons of national
health expenditures across countries gave convincing evidence that the as-
sociation was secondary, mainly due to income differences rather than age
differences, and hence not causal. These findings reinforced the agnosticism
about causality expressed by Newhouse and also prompted greater attention
to methodology and time-​series analysis. Further study made it clear that dif-
ferent results were obtained when the temporal and geographic scale of units
of observation were changed, prompting research on multilevel analysis and
aggregation, as well as a conviction that budget constraints were important.
More data covering longer periods was needed to distinguish noise and
fluctuations from structural shifts in trends. Trolling the archives, reading
history, and seeing the rise of health expenditures in relationship to demo-
graphic transition and the industrial revolution broadened my perspective.
Modern medicine appeared to be a part of national development, intimately
related to social, economic, and political changes. Furthermore, institutions
xviii Preface

and contracts are not details, but functional elements that structure the flow of
medical funds. Understanding why expenditures had grown over the course
of the 20th century required an awareness of how the context and nature of
medical transactions had changed.
Reading government statistical accounts, medical history, studies of eco-
nomic development, and evolution brought together a coherent narrative
about how institutions formed over millennia continued to influence medical
organization in the modern era; why spending had been so small and erratic
in the centuries before 1900 and rose steadily thereafter; why the coalescence
of national health systems after 1950 was coincident with a rapid increase in
expenditures; and how that surge depended on major new investments in
hospitals, professional training, and research. The contemporaneous records
also indicated that regulatory controls over funding and prices were needed to
moderate spending as budget constraints took hold. Please accept that as an
indirect apology for the plethora of citations (over 600) in this book.
From the start, cooperation with those already working on national health
expenditure trends has been essential. Researchers at the US Office of the
Actuary who had begun forecasting US NHE, at the Bureau of Labor Statistics
where the CPI and medical price index were put together, and from the OECD
where Jean-​Pierre Poullier had collected panel data that could be compared
across time and across countries provided essential assistance and helpful
comments. A tentative letter sent to the OECD in Paris brought a surprisingly
detailed five-​page reply. It was the beginning of an extended mentorship that
led me through the intricacies of growth accounting and the complexities of
national archives. My wife and I will never forget an elaborate conference gala
at the Conciergerie on the Quai de l’Horloge where we laughed and dined
with Jean-​Pierre while he repeatedly corrected her French pronunciation.
More pertinently, I ashamedly had to correct all the mistakes he identified in
my English grammar for the articles we wrote together.
Availability of the OECD health data generated significant interest among
health economists and attracted 200 participants to a session held during
the international congress at the University of Zurich in 1990. Afterward, a
newsletter called Health Economic Analysis Letters, or HEAL, was produced
in my office at Temple University and sent out using addresses collected from
those who attended. It appeared irregularly over the next few years and gave
rise to the International Health Economics Association (iHEA) in 1994. Joe
Newhouse, whose paper had initiated my research, generously lent credi-
bility to this fledgling association by agreeing to become its president. Morris
Barer announced an intention to have the University of British Columbia
host a follow-​up to the Zurich congress, and later contacted me to suggest
 Preface xix

that we collaborate and name it the inaugural iHEA World Congress. This
successful event in 1996 was followed by congresses at Rotterdam, York, San
Francisco, Barcelona, Copenhagen, Beijing, Toronto, Sydney, Dublin, and
Milan, allowing me, as the executive director, to become familiar with minis-
tries of health, doctors, and economists around the world.
A class on the macroeconomics of health taught during a sabbatical at York
allowed for refinement of some of the ideas presented in this book, and the
opportunity to become familiar with Tony Culyer and Alan Maynard while
I prepared presentations on the health share of GDP since 1450, measurement
of medical costs, aggregation, and adjustment dynamics, and drafted the first
chapter of a textbook now in its sixth edition from Wiley. The chapter on his-
tory, development, and demography forced a clear and direct expression on
these topics in ways comprehensible to undergraduates and gave me an ex-
cuse to continue researching these areas, while writing the rest of the text-
book pushed me to stay current with a range of topics in all areas of health
economics. A sabbatical at Princeton under the guidance of Uwe Reinhardt
provided intellectual stimulation, conversation, and time for reading history,
writing, and reflection.
Convinced that examination of a well-​defined specific part of medicine
care would help to link micro-​and macro-​level analysis, I benefitted when
a student at Temple who had been a transplant surgeon in Ukraine, Yuriy
Yushkov, suggested that we study tissue banking. Practical insight into non-
profit operations and finance were obtained from interviews with the leaders
of the UNOS organization and the firms that process cadaveric parts for use
in surgical procedures, as did my years on the board and finance committee
of Catholic Health East, which has a large network of hospitals and long-​term
care facilities. A for-​profit start-​up managed behavioral health firm created
by Frank Selgrath in Philadelphia gave me experience with venture capital
and business operations as temporary CFO and board member of a firm with
hopes of going through an initial public offering. Working with a variety of
medical organizations outside of academia gave me a better understanding of
financial and institutional realities, as well as the meaning of organizational
scale and networked relationships.
During the decades spent working on this project, it was apparent
that others were sometimes less enthralled by studies of national health
expenditures. However, when the necessity to project future trends arose,
the usefulness became apparent, as shown by the interest from the OECD,
the US Office of the Actuary, and various ministries of health and finance in
other countries. When legislation required that employers and governments
refine estimation of pre-​funding liabilities for retiree health plans, the Society
xx Preface

of Actuaries requested proposals for assistance, and the SOA has funded the
Getzen Model of Long-​Run Medical Cost Trends for the last 15 years. In ad-
dition to their direct support, the indirect support from many universities,
organizations, associations, and colleagues over many years should be recog-
nized. Years of study have left me with more questions than answers, a chas-
tening awareness of the limits of econometric analysis in the face of complex
systems that have multiple interactions that are neither linear nor constant
and that operate with long and variable lags, and yet a satisfied sense that the
archival data and some preliminary conclusions are worth publishing.
Acknowledgments

Others deserve to be acknowledged here. When I had my first real job as a

venereal disease investigator with the US Public Health Service, patients and
colleagues convinced me that providing care was vitally important, often
messy, and almost always satisfying. Over the next 20 years, three physicians,
Gordon Bergey, Ric Eisenstaedt, and Rich Baron, gave me insights into the
practice of medicine and why it was a worthy and honorable calling despite
the many forced compromises with reality. Yoram Barzel and others in the
Economics Department at the University of Washington showed me how
money always mattered and shaped the institutions of society. Forty years
ago at Temple, Bill Koprowski and Bill Aaronson were doctoral students in
the methods seminar where this project originated. David Barton Smith and
Chuck Hall mentored me as a junior professor, part of a team later joined by
Jacqueline Zinn and Barbara Manaka. Grad assistants David Peknay, Ginny
Elsenhans, Patrick Bernet, Anna Schoenthal, Sonthonax Vernard, and Daniel
Dench helped me to teach and do the research that eventually resulted in
this book. At iHEA, Bill Swan, Patrick Taylor, Chris Pentz, and Christopher
Martin made the operation grow and flourish, as did dedicated colleagues
organizing events including Frans Rutten, Michael Drummond, Richard
Scheffler, Guillem Lopez-​ Casasnovas, Terkel Christainsen, The-​ wei Hu,
Eric Nauenberg, Jane Hall, Charles Normand, and Giovanni Fattore. David
Contosta and Sage Sweetwood are friends who read and made thoughtful
suggestions on introductory chapters. Scott Parris read some early chapter
drafts 20 years before we met by chance in 2015 at the Boston AEA meeting,
where he urged me to complete the work and send it to Oxford University
Press. There James Cook has been my editor, offering insights and shepherding
this work from proposal to final product over the last three years. As is often
the case, the deepest debts are to my family. My children, Matthew and Zoa,
groaned through nights when they were young and I was up producing graphs
on a whining dot-​matrix printer. My wife, Karen, kept us all going while be-
coming a professor and writing her own books. My son, Matthew, read and
revised every single chapter multiple times. Finally, my grandchildren, Kayla
and Zion, may not yet know that they and millions of other grandchildren are
what make research, teaching, and writing worthwhile.
1
Introduction
The Transformation of Medicine

Medicine has been a commercial and social activity for as long as money and
cities have existed. Medical science is now global while medical financing and
regulation are national, with distinct boundaries. Experiences and practices
of medicine are individual and local. All three ranges are needed to describe
modern medicine, yet this layered complexity arose rather recently. For
thousands of years physicians treated specific families and persons rather
than specific diseases. They utilized care, understanding, and traditional cures
rather than technology. Physician-​patient relationships were more important
than scientific knowledge, and personal fees and patronage were more impor-
tant than collective third-​party financing from governments or firms.
Caring is the first and most basic driver of medical practice. Attempts to
relieve pain and preserve human life are a foundation of society. They predate
money, and they predate science. Almost as soon as there was money, medical
care was deemed worth paying for. It remained an important, yet minor, part
of commerce for thousands of years. Only after the rise of scientific medi-
cine in the late 19th century did medical care become expensive and make
paying for hospitals, doctors, and drugs a national policy concern. However,
institutions and norms developed over thousands of years shaped the rise of
modern medicine and will continue to affect its future. This book has a narrow
scope but a long reach, focusing on one economic indicator: growth of health
spending as a share of income. Tracking expenditures as a single continuous
thread over a span of more than 3,000 years provides a guideline for observing
an evolutionary process that resulted in the formation of a distinctively
modern set of medical practices and organizations in the 20th century, a de-
velopment sufficiently complex, with so many events, concepts, regions, and
connections, that it might otherwise resist description and obscure the essen-
tial role of finances. Concern over rising medical costs has become more acute
following the global recession in 2008 and the COVID pandemic in 2019, yet
the underlying fiscal stresses had been building for decades. Understanding

Money and Medicine. Thomas E. Getzen, Oxford University Press. © Oxford University Press 2023.
DOI: 10.1093/​oso/​9780197573266.003.0001
2 Money and Medicine

the dynamics of that financial process and crafting sustainable solutions re-
quire a perspective that extends across centuries.
Histories of medicine are concerned primarily with the development of
medical ideas, science, therapeutics, and clinical practices, somewhat second-
arily with the development of institutions such as hospitals, specialties, licen-
sure, laboratories, research institutes, and schools, and only peripherally with
economics—​the business of medicine and methods of payment. Tracing the
growth of health expenditures from ancient times to the present provides a
new perspective that links the history of medicine to the course of economic
development. A long time series reveals phenomena not visible in short
periods or cross-​sectional analyses. The extraordinary transformation of med-
icine during the 20th century is more readily grasped through comparisons
with the 19th, or by comparing the first 50 years to the second, than comparing
1990 with 1991, or 2009 with 2019. A concentration on year-​to-​year or person-​
to-​person changes is necessary to understand the microeconomics of medi-
cine, but fails to apprehend the macro trends and phase shifts that characterize
the evolution of national health systems and expenditures. While several pre-
vious studies have examined spending over spans of 20 to 50 years, none have
been extended across multiple centuries. From such a long-​term perspective
an S-​shaped logistic growth curve common to biological, social, economic,
and demographic processes becomes visible—​a lengthy period of erratic and
almost negligibly small growth transitioning toward a period of rapid increase
that then decelerates toward a stable plateau (Figure 1.1). For centuries med-
ical expenses essentially matched the growth of incomes (GDP+​0%) so that the
medical share of consumption rose only slightly, if at all. Spending accelerated
with the advent of effective medicine after 1900, reaching a peak around 1970
and then gradually decelerating toward GDP+​1% per year by the end of the
20th century, and is now likely to continue to moderate and eventually reach
a stable and sustainable share of total consumption where the rate of growth is
matched to the rate of increase in income (GDP+​0%).
A recognition that growth in health expenditures can be expressed in ac-
counting and conceptual terms as the amount of money available to spend and
the share spent on medical care is basic to this study. Growth =​GDP +​X% is a
formulation commonly used in contemporary growth models to analyze cur-
rent expenditure trends and project future spending. Separating the determi-
nation of total income (GDP) from changes in the share spent on health care
(X) greatly simplifies the task of health economists, yet can also make it hard
to see that health spending is an integral aspect of a complex social interaction
rather than a variable formed within a detached medical field.
As seen in Table 1.1, human society changed along many dimensions after
1900: life expectancy doubled; most soldiers who were wounded survived;
 Introduction 3

GDP growth + 1% to + 0%

20%
? hypothetical future path

GDP growth + 2% to + 4%

10%

GDP growth + 0% to + 1%

extrapolated
0%
1850 1900 1950 2000 2050 2100

Figure 1.1 S-​Curve Growth in Health Share of GDP, 1850 to 2100

Table 1.1 20th-​Century Transformations

Before 1900 After 2000

Solo doctors National health systems
Personal payments Third-​party financing
< 3% of GDP > 9% of GDP

Life expectancy < 45 Life expectancy > 75

Rural/​agriculture Urban/​services
< $5,000 incomes > $25,000 incomes

almost every sick infant now recovers; doctors became well-​compensated

avatars of science leading teams of technicians; employment in health care
exceeded agriculture and is likely to surpass manufacturing among developed
countries; medical spending tripled; retirement extending over many years
became a personal goal of most individuals and a public financial burden. The
transformation of medicine emerged late in a massive wave of development
encompassing economics, politics, science, and social structure during the
18th and 19th centuries known variously as the industrial revolution, demo-
graphic transition, and the rise of nationalism. Only during the latter half of
the 20th century did the chain of discoveries and institutional advances that
constitute modern medicine coalesce as national health systems capable of
directing a tenth of total economic resources to the medical needs of citizens.
Of particular importance for this inquiry are third-​party medical financing
4 Money and Medicine

institutions for public and private insurance that arose as the scale of risk
bearing and locus of decision-​making shifted from individuals or families to
larger groups and the nation as a whole.
The business of medical care evolved during the 20th century. Patient fees
were replaced with large-​scale pooled funding. What had been a very per-
sonal transaction between doctor and patient became an expensive web
of third-​ party transactions with collective financing totaling billions of
dollars. Payments came from insurance and government agencies rather
than families seeking care. The solo physician gave way to hospitals and
specialty referral networks, with other health professionals, ancillaries, and
technicians outnumbering physicians 10 to 1. Organization and financing
were transformed as medical technology became more efficacious and valu-
able. Spending among the major industrial countries accelerated rapidly after
midcentury, with rates of expansion peaking in the 1970s. Since then growth
has moderated, becoming slower, steadier, and less disruptive.
On the eve of World War I in 1914 the beginnings of modern medicine
were clearly in place among the major industrial nations, yet clinical prac-
tice was just starting to become effective and organized. Only after the Great
Depression, World War II, and decades of scientific research did medical
practice take on its modern form. National health care systems nascent in
the first half of the 20th century became well established by 1975, taking on
shapes that are still recognizable today.
A number of middle-​income countries such as Korea, Turkey, Poland,
Brazil, and Mexico built their own national systems in the following decades,
often relying heavily on the initial Organisation for Economic Co-​operation
and Development (OECD) cohort as models. China, India, and other coun-
tries have now begun to follow. It could be claimed that by 2030 a majority of
the people in the world will be living in countries with comprehensive national
systems that provide and finance health care, although there is a residual set
of less-​developed countries that still lack organized health care for most of
their citizens. These four broad groups of countries form somewhat distinct
cohorts, with most of the historical information and spending estimates avail-
able for those that were already industrialized and established politically in
the 19th century and which were the first to develop national health systems.
Although changes in the economy and conditions of life contributed
as much or more to the transformation of health as changes in the clin-
ical practice of medicine, this book concentrates on the growth of medical
expenditures measured as a share of total income or consumption. Multiple
factors were necessary preconditions for the development of modern medi-
cine and national health systems:
 Introduction 5

• Wealth
• Longevity
• Medical norms and institutions
• Technology
• Financing

Wealth provides a buffer against risk, freedom from malnutrition, and

the ability to invest in knowledge and social capital. Without longevity,
the random risk of sudden death dwarfs the marginal impact of medicine,
making the incremental progress offered by clinical treatment less valuable.
Demographic transition and the industrial revolution made wealth and lon-
gevity available to most citizens among a lead group of developed nations by
the end of the 19th century. Discoveries regarding antiseptics, anesthesia,
bacteria, diagnostics, and the synthesis of organic chemicals laid the scien-
tific groundwork for what would later become modern medical therapeutics.
Precursors of modern organization were provided by the rise of medical li-
censure and of specialty clinics in French hospitals. Financing mechanisms
arose with the formation of friendly societies in England and Bismarck’s
health insurance scheme in Germany. Government actions after 1900 led to
major expansions. As medical care became increasingly effective and expen-
sive, new payment mechanisms were required in order to fund growth and
spread risk. Continued institutional evolution led to national health systems
providing modern scientific medical care through large-​scale public and pri-
vate financing, a core theme of this book.
It could be argued that “national” health expenditures did not really exist
before the rise of modern national governments and are not well defined until
the 20th century, yet the norms and institutions that have shaped modern
medicine in its current form arose over thousands of years. Chapter 2 begins
by reviewing historical evidence from ancient Sumerian codes written
1,700 years before the current era (BCE) to the 19th century. For millennia,
medicine was practiced and honored but largely ineffective in healing disease
or extending life. While there are many records regarding medical practices,
there are only sporadic observations of local financial transactions relating
to them. These indicate that health care expenditures were a persistent but
minor part of the monetary economy, with large differences between urban
and rural settings, across regions, and over time, but no pattern of consistent
growth. Responsibilities for care of the sick that had been taken on by families,
feudal lords, enlightened industrialists, emperors, and kings over 3,000 years
became foundations that would later evolve into national health systems
with broad financial and regulatory duties. Preconditions and context for
6 Money and Medicine

the modern transformation are considered in Chapter 3, concentrating first

on Western Europe, where economic growth and medical science reached a
critical mass before the destructive campaigns of World War I. After that, the
gravitational center of growth and investments in medical science moved to-
ward the United States for the rest of the century. Archival data show that after
slow or negligible growth in average per capita spending across many coun-
tries for many centuries before 1900, health shares in the OECD doubled by
1960, expanding at an annualized rate of more than +​1% a year. An inflexion
point was reached in most OECD countries by 1975 as national health sys-
tems coalesced to provide modern scientific medicine for most if not all cit-
izens, funded collectively with public and private insurance pools that made
advanced treatments accessible even to families with low incomes. Chapter 4
uses detailed graphs and tables to examine trends since 1960 in both devel-
oping and developed countries, based primarily on the contemporary data
sets maintained by the World Health Organization (WHO) and OECD. It
supports the observation that high excess growth rates in the OECD (above
+​3.0% per year) usually coincided with the formation of national health sys-
tems and subsequently decelerated to +​1% a year or less. The shapes and
extent of convergence in trends across nations are addressed, yet cannot be
entirely resolved by the currently available data.
Chapters 2, 3, and 4 provide responses to standard journalistic questions
of what, where, and when and some observations regarding how and why.
The next two chapters deal more systematically with these structural issues.
Chapter 5 addresses scale in financing, delivery, research, organization, and
medical technology as a causal factor in the consolidation of national health
systems, and how scaling up along these dimensions interacted with changes
in political, ethical, and moral scales. Chapter 6 examines the nature of med-
ical transactions and contracts, exploring why medical care is different from
most economic goods. The question “What is the price?” is transformed when
it concerns life and death, as pain and fear become involved, and when the item
being priced (health) is something that can drastically alter the consumption
value of all other goods being purchased. Relational transacting had to evolve
as medical care became a high-​tech necessity vital to the security of ordinary
families and solo physicians gave way to complex organizational networks
that encompassed academic medical centers, satellite hospitals, ambulatory
clinics, diagnostic facilities, and chain laboratories, with outsourcing of pa-
thology, anesthesiology, emergency, and other services. Uncertainty, human
biology, trust, and income distribution can be viewed as adaptive constraints
on monetary flows and social contracts, with the evolution of professional li-
censure, insurance, and voluntary nonprofit medical care as partial responses.
 Introduction 7

Chapter 7 is a case study surveying the United States from 1776 to 2020
in greater depth, offering detail that is unobtainable for many countries.
Tables on workforce, hospital utilization, and payment, along with qualitative
observations on medical organization, licensure, and legislation, give speci-
ficity that illustrates generalizations made in the first six chapters. The United
States became both a technological leader and a financial exception during
the 20th century, with spending per person well above the OECD average.
Yet expenditures did not begin to diverge greatly from the other high-​income
industrialized countries until after 1975. Such anomalous growth is worthy of
careful scrutiny even if no definitive conclusions regarding causality can be
reached. Chapter 8 examines population aging, which is seen to be a signifi-
cant causal factor for the allocation of expenditures at the individual level, but
not a major determinant of growth in aggregate per capita expenditure at the
national level. An observed cross-​country association of per capita medical
spending with percentage of population above age 65 is largely coincidental,
an indirect result of the confounding relationship of economic development
with both population age and national health expenditures (NHE). The age-​
expenditure correlation weakens or disappears once results are appropriately
adjusted for national incomes. At the individual level, average expenditures
per person are always higher for the old rather than for the middle-​aged or
young, and strongly correlated with time to death. Evidence from the United
States shows that the average amounts spent for the elderly relative to the
young vary primarily with changes in national policy rather than health or
mortality risk, and also that the magnitude of time-​to-​death spending effects
falls rapidly above age 65, supporting a thesis that the relationship between age
and spending is a result of budgetary allocation more than biology. However,
it is also clear from the current data and demographic projections that half
of all personal health spending will be allocated to elderly patients in most
OECD countries within the near future.
Chapter 9 explores the dynamics of change over time, differentiating tem-
porary fluctuations from enduring trend shifts. Decomposing the rate of
growth in total expenditures into rates of increase in population, inflation,
per capita income, and “excess” medical cost growth (%NHE − %GDP) helps
to show how business cycles are smoothed and damped by lags of two to
five years in the medical sector. This explains why variations in annual GDP
growth rates have almost no effect on current medical spending while per
capita income trends over 10 years or more are the dominating determinant
of expenditures. Longer and more variable lags due to major scientific dis-
coveries and macroeconomic shocks are made visible by examining spending
over decades and centuries. They frame quantified expectations regarding the
8 Money and Medicine

frequency and magnitude of major turning points that may occur only once
or twice in a hundred years.
Chapter 10 surveys the accounting framework and limitations of the
system of health accounts (SHA) promulgated in 2000 with revisions in
2011 and 2017, then proceeds to more closely examine measurement is-
sues regarding boundaries, categories, and definitions. Understanding the
evolution of medical spending trends rests on understanding why national
observations are now more useful than local, personal, or regional ones; why
annual observations are more useful than hourly, daily, or monthly ones;
and why measurement by decades is usually even more useful, yet measure-
ment by centuries, millennia, or epochs is not. Technology is a major driver
of expenditures but cannot be measured directly. It is most often estimated by
the unexplained residual variance in a time series regression, a rather unsat-
isfying proxy. Since discussions of methodological issues are often of great in-
terest to health economists, econometricians, and historians of social welfare,
but not so much to general readers, they have been deferred to this chapter
near the end of the book and the appendices even though such concerns are
being raised throughout.
Projections of future expenditures are examined in Chapter 11, reviewing
procedures used by the OECD and national authorities. A distinction is made be-
tween “nearcasts” of one or two years where much currently known information
is helpful, and the long-​run forecasts for a decade or more into the future, where
the paths of inflation, regulation, and technology are uncertain. Determining
what variables to include and the frequency of observations depends upon the
length of time to be forecast. Separation of macroeconomic GDP projections
from projections of health sector growth improves forecasting, especially when
combined with adjustment for business cycle lags. Complex multivariate models
including age-​sex decomposition, disease prevalence, treatment prices, and
other factors may be needed to simulate the effects of current events or policy
changes but are seen to yield long-​run forecasts that are usually harder to under-
stand and less accurate than simplified GDP +​X% formulations.
The concluding Chapter 12 reviews the main empirical observation
framing this study, the S-​shaped growth curve of medical expenditures co-
incident with the formation of national health systems, and suggests reasons
why so many previous studies failed to recognize the importance of this long-​
run structure. Four appendices follow containing archival data, documenta-
tion, and commentary.
This book has been written to be of use to specialists in health policy, in-
surance, accounting, actuarial projections, and the macroeconomics of medi-
cine, yet also accessible to general readers with an interest in the development
 Introduction 9

of human social order or the mundane contemporary question “Why does

medical care cost so much?” Some novel elements are brought to bear while
making use of extensive prior efforts by many scholars and commentators.
A coherent narrative expressed visually in Figure 1.1 traces the growth of
health spending over hundreds of years and connects these trends to the flow
of economic, political, and social developments. A new perspective is re-
vealed with this long-​term view that distinguishes three phases of growth: ex-
tended gestation over many centuries, then a rapid rise over seven decades
culminating in the coalescence of modern national health systems, followed
by 50 years of postmodern deceleration troubled by continued excess cost
growth without commensurate gains in health due to diminishing marginal
returns.
The essential elements and contributions of this study can be stated suc-
cinctly. Medical institutions and expenditures evolved over time. Certain so-
cial norms and institutional features reach back over millennia, while modern
scientific medicine, organized clinical networks, collective financing, insur-
ance, and universal access are 20th-​century developments. Focusing on a
single variable (expenditures) and formulating growth as GDP +​X% is not
only a useful simplification of a complex process, it demonstrates why the
core economic problem for health policy is not the amount spent, but the fact
that medical expenditures keep increasing faster than incomes. Scale matters.
Micro factors determining the allocation of expenditures for specific patients,
doctors, or hospitals are quite different from the macro factors determining
total national health spending. Patterns of expenditure over days, months,
or years are different from the pattern over decades or centuries. The health
system is inertial. There are lags of years or decades before a scientific dis-
covery or macroeconomic event has a visible effect upon medical spending.
As medical care scaled up along clinical, ethical, organizational, political, and
financial dimensions it was quantitatively and qualitatively transformed—​a
phase change marked by an inflexion in growth rates of the health sector and
the formation of national health systems.
2
Hammurabi to Middlemarch,
1750 bce to 1850 ce

Historical Review

Medical care has been a small yet significant expenditure for as long as there
has been money. Specific payments are recorded in the Code of Hammurabi
(c. 1755 bce): “If a physician make a large incision with a knife and cure it, or if
he opens a tumor over the eye and saves the eye, he shall receive ten shekels of
silver. If the patient be a freed man, five shekels. If he be the slave of someone,
his owner shall give the physician two shekels. If a physician make a large inci-
sion with the operating knife, and kill him, or open a tumor with the knife and
cut out the eye, his hands shall be cut off.”1 It is remarkable that regulations
of medical quality and prices are present on this carved cuneiform stele, one
of the oldest known government legal proclamations. The medical profession
must already have been well established by then, as there are references to
physicians with the names Lulu (c. 2700 bce) and Hesy-​ra (2650 bce), and a
specific hieroglyph for “doctor” (SeWNeW) occurs repeatedly among the ear-
liest Egyptian Old Kingdom documents.2 Fragmentary evidence of medical
practices in the 2nd and 3rd Dynasties is presented in the Kahun (1800 bce),
Smith (1600 bce), and Ebers (1550 bce) papyri and was presumably copied
from even earlier sources.
Similar fee tariffs and rules regarding fraud and malpractice are found in
the Persian Videvdad (c. 700 bce) and other Middle Eastern sources during
the following centuries.3 The Videvdad also distinguishes among types of phy-
sician: “If several healers offer themselves together, O Spitama Zarathustra,
namely one who heals with the knife, one who heals with herbs, and one who
heals with the holy word, it is this one who will best drive away sickness from
the body of the faithful.” Itinerant physicians using surgery or medications
often occupied a lower status than the healing diviners attached to temples.4
The intent of this chapter is to accumulate archival data and anecdotes
sufficient to enable reasonable judgments regarding the growth of med-
ical expenditures from ancient times to the 19th century, document the

Money and Medicine. Thomas E. Getzen, Oxford University Press. © Oxford University Press 2023.
DOI: 10.1093/​oso/​9780197573266.003.0002
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 11

historical development of medical science and therapeutics, and support

some generalizations regarding the evolution of medical spending and
institutions over thousands of years that have implications for the modern
and postmodern trends examined in Chapters 3 and 4.5 An overview of the
available records, even the necessarily brief presentation made in this chapter,
makes it clear that medical spending was uneven and erratic for many centu-
ries, growing very slowly if at all as a share of income or consumption from
1800 bce to 1850 ce, and can help to clarify why it took 3,600 years for major
changes in the practice and financing of health care to occur.
Herodotus admiringly noted that Egyptian medicine was sufficiently ad-
vanced for physicians to specialize in particular diseases—​ophthalmology,
gynecology, proctology, surgery, or dentistry. The picture obtained from these
sources shows a mixture of secular and supernatural causality—​empirical
medicine as well as divination and spirit possession. Imhotep is sometimes
identified as the first physician, but also as chancellor and high priest, a multi-
plicity of roles consonant with an Egyptian society in which theology, politics,
and science were combined in a single bureaucracy operating under the rule
of a divine pharaoh.
Writings attributed to Hippocrates of Cos (c. 420 bce) emphasize a natural
balance rather than supernatural causes.6 Unlike the Egyptian physicians who
operated as part of a political and theological bureaucracy under the pharaoh,
Greek physicians of the 3rd and 4th centuries bce appear to have been en-
gaged in ordinary commercial practice. Dependent on paying patients, the
Hippocratic oath establishes principles of fair competition, including an ad-
monition against intruding on “cutters of stone,” who presumably belong to a
distinct and separate professional group (see Appendix C on ethical codes). In
addition to the rational, balanced lifestyle medical practice attributed to the
itinerant physicians following Hippocrates and similar schools, the Temples
of Aesculapius provided a tradition of magical treatment with “incubation,”
where patients would come to be purified within the divine shrines in order to
have a dream specifying a cure for their illness or receiving direct intervention
from the health divinity while they slept. Aegean cities were often served by all
three types of healers: surgeons, herbal doctors, and incantation priests.
With the rise of Rome, many of the most admired Greek physicians
migrated there for professional advancement.7 Galen (129–​200 ce) was by far
the most famous and was revered for more than a thousand years as founder of
the European medical tradition. De Materia Medica by Pedanius Discoridies
(c. 40–​90 ce) was in use for centuries, listing more than 600 herbal cures. The
strength of the Roman Empire depended upon the strength of the Roman
army, and that army relied upon a system of valetudinaria, army hospitals
12 Money and Medicine

accommodating up to 500 men, to maintain health and morale. Military med-

icine was organized and efficient. Richard Gabriel makes a credible case that it
was not until the 20th century that most armies were able to match the quality
of care provided to Roman soldiers or better deal with battlefield wounds and
diseases.8
In Roman-​ruled Judea, Christian parables such as the story of the Good
Samaritan emphasized a responsibility to care. Biblical awareness of the cost
of secular medical care is provided in Mark 5:25–​26: “And there was a woman
who had a flow of blood for twelve years, and who had suffered much under
many physicians, and had spent all that she had, and was no better but rather
grew worse.” Christian monasteries developed a tradition of care during the
later centuries and created hospices for weary travelers as well as offering
shelter and comfort to the poor and sick across much of Europe. The domi-
nant Christian view that disease was a result of sinful behavior to be amelio-
rated by faith rather than empirical remedies or science led to a stagnation
and decline in medical knowledge throughout the European Dark Ages.
Classical works by Galen and Discoridies were lost in the aftermath of the
fall of Rome and not brought back to Europe until Greek and Latin texts that
had been translated into Arabic during the Islamic Golden Age were restored
to the canon. Rhazes (Muhammad ibn Zakariya al-​Razi, 854–​925 ce) wrote
numerous medical texts, and his collected notes, Kitab al-​Hawi, translated
into Latin in the 12th century, was considered by many medieval scholars as
the most comprehensive available source. Rhazes performed a basic type of
clinical trial, comparing the outcomes of meningitis patients treated with and
without bloodletting.9 The Canon of Medicine (al-​Canon fi al Tib) by Avicenna
(Abdullah ibn Sina, 980–​1037 ce) was used as a textbook in Islamic and
European schools until the 18th century, and still plays an important role in
Unani medicine. Averroës (Ibn Rushd, 1126–​1198 ce), born in what is now
the Spanish city of Córdoba, wrote commentaries on Aristotle and medicine
that helped bring these ancient texts to medieval European universities and
rebuild a tradition of medical scholarship, with faculties of medicine created
at Salerno (c. 950 ce), Bologna (1068 ce), Oxford (1067 ce), Paris (1150 ce),
Prague (1348 ce), Vienna (1365 ce), Heidelberg (1386 ce), and other centers
of learning.10 The modern economic historian Carlo Cipolla compiled data
on the number of physicians relative to population in several Renaissance
Italian cities, presented in Table 2.1.11 He cautions that “it would be absurd to
pretend statistical precision for the period in question and the figures have to
be taken simply as orders of magnitude.” Nevertheless, this provides perhaps
the first set of numbers able to quantify early health expenditures on a popu-
lation basis. Cipolla notes that in 1324 the city of Venice, with a population of
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 13

Table 2.1 Number of Physicians Relative to Population in Renaissance Italy

Physicians in Italian Towns: 1288 to 1675

Year # Physiciwans Pop. (000s) Phys./​1,000

Milan 1288 28 60 0.5

Verona 1409 6 20 0.3
Como 1439 2 9 0.2
Verona 1456 17 20 0.9
Verona 1502 18 40 0.5
Verona 1545 21 45 0.5
Verona 1605 22 60 0.4
Carmagnola 1621 2 7 0.3
Florence 1630 33 70 0.5
Pisa 1630 12 13 0.9
Rome 1656 140 120 1.2
Rome 1675 164 130 1.3

Source: Cipolla (1973, p. 41).

about 100,000, was served by 13 physicians and 18 surgeons who received a

salary from the community to serve the poor, as well as an unknown number
in private practice (including apothecaries, who filled prescriptions and were
prohibited from association with physicians). He goes on to assert that in
northern Italy, the professional service sector had already reached levels in the
13th century that were not surpassed until the end of the 18th.
Distinctively different medical systems were developed outside the
Mediterranean region in China, India, and Mesoamerica, yet all of these sys-
tems contained blends of secular and supernatural causation, using religion to
promote health as well as relying on herbs and other materia medica similar
to those of Mesopotamia, Greece, and Rome. Ayurveda (science of life) is per-
haps the oldest systematic form of medical practice, having originated prior
to written records in the Indus Valley; it was codified during the Vedic pe-
riod more than 2,000 years ago in the Charaka Samhita and Sushruta Samhita.
Emphasis is placed on a balance of bodily forces combined with lifestyle and
diet, similar to the balance of humors conceptualized in Hippocratic medi-
cine. Ayurveda is still relied upon by much of the Indian and Nepalese pop-
ulation today, often in combination with contemporary Western practices.
The Indian Ministry of AYUSH (Ayurveda, Yoga and Naturopathy, Unani,
Siddha, and Homeopathy) maintains research institutes and over 180 official
training centers granting educational degrees. Traditional Chinese medicine
14 Money and Medicine

is similarly ancient and has developed specialized practices such as acupunc-

ture, moxibustion, tai chi, and qi gong, used in combination with herbal
infusions and diet. Traditional Chinese medicine is still popular in its home-
land and, like Ayurveda, has limited but widespread practice as a form of
complementary medicine throughout the modern world.
The idealization of Hippocrates and Galen as ruling exemplars of med-
ical practice was a combination of hagiographic mythologizing and culling
from multiple translated and incomplete source documents that took place
over hundreds of years. A new spirit of scholarly inquiry arose during the
13th century European Renaissance, first trying to recapture the wisdom of
ancient genius and then leading to a raft of discoveries in the 16th, 17th, and
18th centuries that laid the foundation for a new science of medicine. The
Canon of Avicenna, grounded in the authority of Hippocrates and Galen,
was translated into Latin by Gerard of Cremona around 1120. The texts were
later revised and improved by Andrea Alpago, a Venetian who had worked
in Damascus for many years and spoke Arabic fluently. In 1527, several
years after his death, this version was published and subsequently reprinted
30 times, showing the power of a new technology, printing, to dissemi-
nate knowledge across Europe during the 16th century. Learned doctors at
European universities relied upon the authority of Galen and Hippocrates,
writing commentaries and elaborations of established doctrine. Most uni-
versity graduates were deemed capable of acting as physicians regardless of
any preparation with actual patients. Upper-​class physicians looked down
upon common healers trained only by apprenticeships and experience, even
though such “uneducated” practitioners were relied upon by most people for
care since they often had better procedural skills and knowledge of how drugs
worked in practice. Those who relied upon clinical experience or new theories
were apt to be derided as mere “empirics” by elite educated physicians who
proudly maintained the superiority of their learned traditions passed down
for a thousand years. Even expert surgeons were disparaged for working with
their hands rather than depending on classical philosophy. Authority, not ex-
periment, ruled the medical colleges.
Intellectual rigidity crumbled during the Renaissance as new discoveries
were made and old certainties discarded. Leonardo da Vinci’s notebooks
dating from 1489 to 1514 provided a more realistic vision of anatomical
details. Andreas Vesalius’s illustrations of the liver, reproductive organs,
and skeleton, published in 1539 as Tabulae Anatomicae, were popular with
students. Yet much of Vesalius’s early work still followed Hippocrates and
Galen rather than nature. Over time, direct observation made Vesalius more
and more critical of that earlier work. Asserting that anatomy could only be
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 15

learned through human dissection, he published revised views in De Humani

Corpus Fabrica (1543), correcting many errors that had been passed down for
centuries.
Paracelsus (Theophrastus Bombastus von Hohenheim) famously challenged
the authority of Greek and Arabic medical classics. City physician and pro-
fessor at the University of Basle from 1526 until he was forced to leave in 1528,
Paracelsus claimed both to be the heir of ancient traditions and to surpass them.
He sensed that the world was facing imminent change and preferred to make
his own studies in biology and chemistry, as well as to immerse himself in spir-
itual Christianity, astrology, and magic, arriving at an arcane cosmology and the
theory that each illness had a specific chemical cure. Paracelsus became very
popular in the period immediately after his death, yet the occult character of his
esoteric ideas made them a subject of scorn later. They are, however, now recog-
nized as having been a liberating force dislodging old certainties.
After studies at Padua, William Harvey studied medicine at Oxford, then
published De Motu Cordis in 1628, replacing Galen’s mistaken concept of
blood sloshing up and down with the radical idea of circulation. Despite
having made such an important discovery, Harvey remained comfortable
with most of the older tradition. Advancing technology, especially the inven-
tion and refinement of the microscope, was soon to revolutionize medical
thought, bringing it more into alignment with the mechanistic perspective
expressed by Descartes. Anton van Leeuwenhoek was able to refine the mi-
croscope to a magnification of 400× and see individual blood cells. Marcello
Malphigi described the fine structure of the lungs, where blood is revitalized.
Robert Hooke’s Micrographia, published in 1665 by the newly formed Royal
Society, where he served as curator of experiments, provided descriptions
and illustrations of kidney stones, fleas, lice, and bee stings. The Philosophical
Transactions of the Royal Society became the first journal exclusively devoted
to science and has stayed in continuous publication through the present day.
The 17th century was filled with innovation and intellectual excitement.
Copernicus and Galileo revolutionized the view of the stars and humankind.
Isaac Newton built the first reflecting telescope in 1668, published Principia
Mathematica in 1687 and Optics in 1704, and served as president of the Royal
Society from 1702 until his death in 1727. Among the early studies published
for the society, Natural and Political Observations Made upon the Bills of
Mortality by John Graunt, published in 1662, is perhaps the most important
for the history of health care. From Graunt’s tables, the Dutch mathemati-
cian Christian Huygens was able to make computations of life expectancy. Sir
William Petty was a mentor to Graunt and may well have been the co-​(or pri-
mary) author of Graunt’s Observations. Petty had been a professor of anatomy
16 Money and Medicine

at Oxford and an active participant in the government. His 1667 proposal Of

Lessening Ye Plagues of London, which tabulated the costs and benefits of an
evacuation plan, could be considered the first quantified health economic
evaluation (for which he not so humbly asked Parliament to provide him a
reward of 20 shillings per death averted for reducing the loss in taxes—​see
Appendix D).12 Petty was identified as the founder of econometrics by Joseph
Schumpeter in the 20th century for having been the first to use data rather
than anecdotes when he calculated the gross national income of England in
his 1686 treatise Political Arithmetik.
The ascent of science continued during the 18th century. Bayes developed
his principles of inference. Laplace and Gauss derived the normal distribu-
tion. Newcomen and Watt developed the steam engine. Quesnay constructed
the Tableau Économique, Adam Smith published The Wealth of Nations, and
Malthus wrote An Essay on the Principle of Population. Lavoisier discovered
oxygen. Linnaeus systematized biology. Humboldt quantified travel records
to explore biogeography. Galvani and Volta conducted experiments showing
that nerves and muscles responded to electricity. Boerhaave, elected to both
the French Academy of Sciences and the Royal Society of London, instituted
clinical education and incorporated chemistry into the curriculum of medical
schools across Europe, becoming known as the “father of physiology.”
Despite the expansion of knowledge, treatment of disease remained little
changed. Bloodletting and purgatives were the most common therapeutic
interventions for most of the 19th century.13 Materia medica contain hun-
dreds of herbal and mineral cures, and also the common cure-​all theriac or
“Venice treacles” that was a compound of many substances, often including
snake, bat, or insect parts in addition to plant material.
Edward Jenner’s introduction of vaccination using cowpox in 1796 was much
safer than inoculation, and an important step toward the eventual elimination
of smallpox in the 20th century, yet this was a form of prevention, not cure.
James Lind dealt with a deficiency disease rather than an infection in his 1753
Treatise on Scurvy. Lind’s controlled trial on 12 sailors, giving six citrus and six
regular food and treatments, marked an important methodological advance in
medical research, but the use of limes was more often preventive than curative
in subsequent years. In the first half of the 19th century Laënnec invented the
stethoscope, von Helmholtz the ophthalmoscope; Röntgen discovered X-​rays;
Semmelweiss introduced antiseptic measures at the Vienna lying-​in hospital to
reduce deaths from puerperal fever; and the first edition of Gray’s Anatomy be-
came a standard text. However, Acknerknecht observes that the study of path-
ological anatomy that had made the Hôtel-​Dieu in Paris a beacon of progress
and center of learning attracting hundreds of foreign students at the end of the
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 17

18th century essentially reached a dead end by 1850.14 Even as late as the 1880s
and 1890s many doctors were still much taken with medical nihilism—​a view
that scientific methods might bring better understanding, prevention, and prog-
nosis but could do little to provide actual cures. The first edition of William
Osler’s Principles and Practice of Medicine in 1892 went to some length to extol
diagnosis while discouraging therapeutic optimism.15 Christian Science, hy-
drotherapy, homeopathy, and Thomsonianism flourished in the United States,
and the Harvard Medical School was classified as “eclectic,” embracing multiple
forms of practice including allopathy.
The novel Middlemarch, published in 1871 but set in the 1820s, features a
young Dr. Tertius Lydgate among its cast of characters in an English Midlands
village. The intricacies and intrigues of this naturalistic novel can be set aside
to focus on its portrayal of medical practice and professional advancement
in that period.16 Notably, advancement comes from peer recognition, having
rich families as clients, and being in London. Young Lydgate studied in Paris,
indicating that he was progressive and intellectually engaged with the latest
ideas, but he struggles in the provincial village of Middlemarch as his plans for
doing important scientific research, maintaining high ethical standards, and
earning a comfortable living all fade, with the last of these disappointments
being most troublesome for his ambitious spouse. Lydgate is isolated,
practicing alone, with only occasional consultations with other doctors. He
may have a university education and have been trained in a hospital, but he
does not have access to or support from those organized institutions. As a solo
physician, his personal relations, commercial transactions, and ability to cure
are not dissimilar to those in ancient Sumer 3,000 years before.
After remaining much the same for millennia, the practice of medicine un-
derwent rapid and radical change. While the brief potted history of medicine
outlined above is hardly a substitute for the extensive scholarship on the sub-
ject, it does indicate how much had been accomplished before 1850, and how
little therapeutic benefit could be shown to have resulted from it—​a conclu-
sion reinforced by the failure to observe substantial improvements in ordinary
mortality rates over time, moving from the main civilization centers of the
Tigris and Euphrates to the Nile to the Greek Isles to Rome, Constantinople,
Vienna, Paris, and London.17

State Medicine, Hospitals, and Public Health

From the pharaohs to Queen Victoria, provision of medical care was a part
of the compact that constituted the state—​an obligation of the rulers to the
18 Money and Medicine

ruled. The church and the army were two pillars of elite power.18 Both faced
the conundrum of maintaining a privileged elite while obtaining loyalty from
large numbers of peasants or soldiers who had little opportunity to be ele-
vated. Providing medical care, giving life itself, was a way to bind the many to
the few. Doctors were part of the theocratic bureaucracy in Egypt and of the
English navy.19 Rosen’s History of Public Health describes public physicians
in Greek city-​states paid to provide care for citizens and transients, and also
the Roman practice of building aqueducts to provide clean water and grain
storehouses to prevent famine among the masses.20 Quarantine had been
used by city and state governments to avoid or limit epidemics since early
times. The English Parliament set out a national policy to be paid for by a local
tax on houses and other buildings in 1578. The plagues that had decimated
populations in the Middle Ages were virtually eliminated in England by 1670,
in the rest of Europe by 1750, and within the Ottoman Empire by 1840.21 It is
important to note that this was an administrative success, a gain attributable
to public health measures rather than therapeutic medical interventions with
individual patients.
The protection of public health through quarantine was one goal of the
1,900 lazarettos or leper hospitals counted across Europe in the 13th cen-
tury.22 Another was to establish a place for these displaced diseased persons
to live out their lives. The rise of Christianity is associated with the expan-
sion of monastic hospitality from a guesthouse to an institution serving the
poor and sick that occurred over many centuries, reaching an early peak with
the Pantokrator Xenon in 12th-​century Constantinople, with five wards and
a staff of six rotating physicians, and a later peak in the 15th to 18th centu-
ries with the Hôtel-​Dieu of Paris, which had specialized clinics and physicians
teaching cohorts of medical students from England, Germany, America, and
elsewhere.23 The maintenance of hospitals dovetailed with a long-​standing re-
ligious tradition of providing care to strangers and the homeless poor, or eld-
erly men and women for whom there was no place within the family. Hospitals
were often voluntary—​charitable institutions overseen by a board of digni-
taries from the local community in England and the United States, but more
often run and funded by the state on the European continent.24 Hospitals did
not become “medicalized” until the 19th century, and did not depend on pa-
tient payments for financing until the 20th century.
Almshouses served both the poor and the sick, relying on parish or local
government funding. That functionality also applied to the mental hospitals
that housed some 10,000 people in “madhouses” such as Bethlehem (also
known as Bedlam) in England in 1800, rising to 100,000 by the end of the cen-
tury. The highly commercialized culture of the Netherlands in the 15th–​18th
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 19

centuries gave rise to an unusually strong development of specialized facili-

ties for care of the elderly that would today be called “nursing homes” or “as-
sisted living” that were funded commercially through private fees as well as by
municipalities.25
Governing authority has always come with some set of responsibilities
for health care. In addition to relief of famine and plague, regulation of the
medical profession (and sometimes of prices), it has included medicine and
doctors for the army as well as food and shelter (and perhaps some medical
care) for the poor, displaced, infirm, and elderly. The US Public Health Service
originated in a merchant seamen’s hospital founded in 1798, responding to
the need for quarantine and providing long-​term care for disabled and aged
sailors whose work was vital to shipping and industry but had no family or
local parish to give them shelter once infirmities ended their days at sea.
English hospitals and poor laws existed for centuries before the regulation
of doctors was legislated in the Medical Act of 1858. Great Britain had long
played a leading role in research, education, and social care even though few
citizens received medical treatment from the state. Parliament and the City of
London undertook massive reforms to provide sanitation and reduce the risk
of waterborne disease. Edwin Chadwick’s Report on the Sanitary Conditions
of the Labouring Population of Great Britain was published in 1842, and a
General Board of Health with broad powers was formed by the Public Health
Act of 1848.26 After resistance led to repeal, another Public Health Act was
passed in 1875. The “sanitary revolution” of the late 19th century that began to
rapidly bring down the horrendous mortality associated with crowded living
conditions in cities across the world was vital to the rise of modern medicine
in the 20th century.

Medical Effectiveness and Expenditures from 1800

bce to the 19th Century ce

There was no major or sustained improvement in health or medical care

during the 3,000 years before the 18th century. This negative conclusion is
supported by the lack of any substantial improvement in life expectancy and
mortality rates. It is not that there were not times and places that experienced
better health—​some Egyptian settlements along the Nile, cities of Mycenaean
and classical Greece, Rome, Carthage, and parts of the Byzantine Empire ex-
perienced much better lifestyles and longevity than the average—​but there is
no reliable evidence of long-​term improvement, and conditions in most of
Europe deteriorated during the Dark Ages.
20 Money and Medicine

Local health has been heterogeneous throughout history, one town or vil-
lage enjoying health and old age while another was pestilential and death
came early. The incidence of disease and of expenditures for medical care was
also very irregular and highly concentrated across families. Medicine over
these three millennia can be characterized as having money and expertise
concentrated at the top, with the bulk of care provided to the masses by family
members and experienced but uneducated healers or midwives. Governments
provided medical care in the army, navy, and other parts of the bureaucracy,
with most charity care provided locally and often under religious auspices.
While mortality rates for different centuries can often be estimated indirectly,
for spending there is only anecdotal evidence and sparse scraps of data for
limited periods of time and numbers of people.
Ancient Egypt was a theocentric and mostly nonmonetary barter
economy. Physician “incomes” depended primarily on status and close-
ness to the pharaoh rather than on services rendered.27 Even in the
2,000 years of the current era, it is difficult if not impossible to reliably
estimate changes over time in average per capita costs, the fraction of
total spending devoted to medical care, the number of doctors relative
to population, or the size and complexity of medical organization. Most
civilizations had multiple types of medical practitioners with different
levels of privilege and practice, while most care was provided in the home
by servants or family members. In Greece, certain practitioners were des-
ignated as public doctors for the city and were given titles of honor, exemp-
tion from city taxes, and salaries in addition to their earnings from private
patient fees.28 Similar designations were found in Rome and Byzantium,
but the vast majority of care was provided by regular and irregular healers
rather than this elite.
Medical occupations and monetary expenditures for drugs, diagnosis,
surgery, and care become increasingly important in the late 19th and early
20th centuries. Thomas Carlyle lamented the passing of an earlier period
when “Cash Payment had not then grown to be the universal sole nexus of
man to man.”29 Increased reliance on patient payments led to a democra-
tizing shift in power away from patrons and toward patients.30 Hospitals
were becoming “medicalized,” treating acute illnesses rather than ware-
housing the poor and disabled. Even well-​to-​do shopkeepers were now
being admitted as inpatients for surgery and recovering from serious
illnesses in hospital beds rather than relying on servants and private nurses
at home. Most quantified extrapolations must be made from the sparse
European data available or inferred from anecdotes. Historical records
of traditional Chinese medicine or Ayurveda do not appear to document
 Hammurabi to Middlemarch, 1750 bce to 1850 ce 21

distinctive financial arrangements or institutional structures; hence it is

assumed that they were broadly similar, with various combinations of gov-
ernment funding and private fees.
The Cipolla data presented in Table 2.1 are arguably the first figures that
allow for quantified estimates related to health expenditures on a popula-
tion basis. Budgetary surveys were carried out by David Davies in 1795 and
Frederick Morton Eden in 1797 to study the effects of poverty and rising
prices on the working classes.31 Among the 127 agricultural workers’ families
surveyed by Davies, 72% of total spending was for food, 9% for clothes, 5%
for rent, and 3.9% for medical care. Davies and Eden presented their data raw
as compilations or anecdotes, so even the percentage calculation is a modern
emendation.
A major budget study of 153 Belgian families was conducted by Edward
Duceptiaux in 1855 and subsequently used by Ernst Engel in 1857 to con-
struct income-​consumption graphs known as Engel curves that supported
a generalization referred to as Engel’s law: “The poorer a family, the greater
proportion of its total expenditure that must be devoted to food”—​implic-
itly inferring that greater wealth led to increases in the remaining catego-
ries. “Health and other” accounted for 1.7% of income among the indigent,
2.8% among the working poor, and 4.3% among the comfortably well-​off
(Table 2.2).32

Table 2.2 Consumption of 153 Belgian Families, 1853

On relief Poor but Comfortable

independent

Average income (francs) 545 797 1,198

Average expenditure 649 845 1,214
Category of Expenditure in %
Food 70.9% 67.4% 62.4%
Clothing 11.7 13.2 14.0
Housing 8.7 8.3 9.0
Heat and light 5.6 5.5 5.4
Tools and work supplies 0.6 1.2 2.3
Education, religion, etc. 0.4 1.1 1.2
Taxes 0.2 0.5 0.9
Health, recreation, insurance 1.7 2.8 4.3
Personal services 0.2 0.2 0.4

Source: Stigler (1954).

22 Money and Medicine

Distribution of expenditures across families within each group was even

more uneven due to the erratic incidence of illness. It was also highly disparate
across localities. Medical resources were concentrated in cities, especially the
major technological centers such as Berlin, Paris, London, and Boston. The
services extended to some workers in the coal, steel, and other new industries
were largely unavailable to farm laborers and the great majority of the popula-
tion. This makes computation of “average” expenditures difficult and perhaps
not very meaningful. When large-​scale collection of spending data does be-
come available in the 1930s, it shows 10-​fold differences in per capita spending
among the various regions within a country, and equally large differentials
across neighborhoods and families within a region. It should also be noted
that early consumption surveys often included the cost of funerals and re-
placement of lost wages in the category of “sickness” spending.33 In order to
estimate levels and trends in national per capita medical expenditures, it may
be more reliable to use occupational data as a proxy, measuring the size of
the medical workforce relative to total employment or to total population as a
proxy for the share of GDP spent on health (see Appendices A and B for more
detailed discussions of sources and methods of extrapolation).
In 1600 the 200,000+​inhabitants of London were reported to have about 50
physicians, 100 surgeons, 100 apothecaries, and 250 “other” practitioners.34
When the first English medical register was published in 1779, the 3,000
doctors listed were but a fraction of the full-​or part-​time healers in practice,
and the title “physician” was limited to an educated few, probably numbering
under 200.35 Occupational data can be used to construct time series using the
decadal censuses of Great Britain from 1841 onward and from 1850 onward in
the United States (Tables 2.3 and 2.4).36

Table 2.3 Occupations of People in the United Kingdom, 1841–​1891

1841 1851 1861 1871 1881 1891

Doctor 17.1 19.2 18 19.2 21.2 20.9

Druggist 10.1 14.3 16.4 19.7 19.0 21.9
Dentist 0.6 ** 1.6 2.3 3.6 4.9
Midwife 0.7 2 1.9 2.2 2.6 **
Med. service 13.9 24.8 25.4 29.2 37.2 58.1
Tot. medical 42.4 60.3 63.3 72.6 83.6 105.8
Tot. occupied 5,846 8,117 9,185 10,281 11,188 12,649
% medical 0.7% 0.7% 0.7% 0.7% 0.7% 0.8%
Note: Numbers in thousands.
Sources: Booth (1886); Armstrong (1972).
Another random document with
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 14‒16. The great disaster which befell Amaziah at the hands of
Joash king of Israel and which is about to be narrated in verses 17‒
24 seemed to require some heinous transgression for its cause. This
the Chronicler supplies in the assertion that, after the defeat of
Edom, Amaziah actually brought back Edomite images and set them
up in Jerusalem for worship (verses 14‒16): a truly horrible result of
a victory which had resulted from obedience to Jehovah’s word by
His prophet!

¹⁴Now it came to pass, after that Amaziah

was come from the slaughter of the Edomites,
that he brought the gods of the children of
Seir, and set them up to be his gods, and
bowed down himself before them, and burned
incense unto them.
14. bowed down ... and burned incense] The tenses in the
Hebrew are imperfects and imply that this became Amaziah’s
practice. The act was according to a policy frequently pursued in
ancient times. Solomon affords an instance of it (1 Kings xi. 7).

¹⁵Wherefore the anger of the Lord was

kindled against Amaziah, and he sent unto
him a prophet, which said unto him, Why hast
thou sought after the gods of the people,
which have not delivered their own people out
of thine hand?
15. which have not delivered] Such deliverance being in popular
thought the proof of a deity’s power; compare Isaiah xxxvi. 18 ff.,
xxxvii. 18 ff.
 ¹⁶And it came to pass, as he talked with him,
that the king said unto him, Have we made
thee of the king’s counsel? forbear; why
shouldest thou be smitten? Then the prophet
forbare, and said, I know that God hath
determined to destroy thee, because thou hast
done this, and hast not hearkened unto my
counsel.
16. of the king’s counsel] Literally, “counsellor to the king.”

hath determined] Literally, “hath counselled” (with a play on the

king’s word).

17‒24 (= 2 Kings xiv. 8‒14).

Amaziah Conquered by Joash.

The overwhelming defeat of Amaziah by Joash of Israel,

involving the destruction of part of the defences of Jerusalem and
the plundering of the Temple, must have been an affair of the highest
importance in Judean history. The relative weakness of Judah
compared with Israel is still less apparent in Chronicles than in
Kings. For a discussion of the evidence see Cook in Encyclopedia
Britannica, s.v. Jews, p. 379.

¹⁷Then Amaziah king of Judah took advice,

and sent to Joash, the son of Jehoahaz the
son of Jehu, king of Israel, saying, Come, let
us look one another in the face.
17. took advice] Took counsel, presumably (according to the
Chronicler’s narrative) with a view to demanding satisfaction from
Joash for the ravages of the Israelite mercenaries (verse 13). The
sequel suggests that Joash refused to give satisfaction.
 let us look one another in the face] The proposal may be either to
fight or (better) to discuss Amaziah’s claims, the two kings meeting
as equals. The latter is probably the right alternative, for the answer
of Joash draws a scoffing parallel between Amaziah’s proposition
and a thorn’s proposal of alliance with a cedar. Had Amaziah’s words
been a challenge to fight, Joash’s answer might rather have taken
the form of the parable in Judges ix. 15, “The thorn said, Fire shall
come out of the thorn and devour the cedars of Lebanon,” etc.

¹⁸And Joash king of Israel sent to Amaziah,

king of Judah, saying, The thistle ¹ that was in
Lebanon sent to the cedar that was in
Lebanon, saying, Give thy daughter to my son
to wife: and there passed by a wild beast that
was in Lebanon, and trode down the thistle.
¹ Or, thorn.

18. the thistle] margin, thorn; compare Proverbs xxvi. 9 (same

Hebrew word).

¹⁹Thou sayest, Lo, thou hast smitten Edom;

and thine heart lifteth thee up to boast: abide
now at home; why shouldest thou meddle to
thy hurt ¹, that thou shouldest fall, even thou,
and Judah with thee?
¹ Or, provoke calamity.

19. Thou sayest] i.e. to thyself.

meddle to thy hurt] margin, provoke calamity, i.e. by making

claims which he could not enforce.
 ²⁰But Amaziah would not hear; for it was of
God, that he might deliver them into the hand
of their enemies, because they had sought
after the gods of Edom.
20. for it was of God] Not in Kings. This turn is characteristic of
the Chronicler; compare x. 15, xxii. 7.

²¹So Joash king of Israel went up; and he and

Amaziah king of Judah looked one another in
the face at Beth-shemesh, which belongeth to
Judah.
21. he and Amaziah ... looked one another in the face] The
historian by a kind of irony takes up Amaziah’s phrase (verse 17)
and gives it a fresh application. Compare the double application (by
a similar irony) of the phrase, “lift up the head” in Genesis xl. 13, 19.

at Beth-shemesh] Compare 1 Chronicles vi. 59 [44, Hebrew]

(note).

²²And Judah was put to the worse before

Israel; and they fled every man to his tent.
22. to his tent] Compare vii. 10 (note).

²³And Joash king of Israel took Amaziah king

of Judah, the son of Joash the son of
Jehoahaz, at Beth-shemesh, and brought him
to Jerusalem, and brake down the wall of
Jerusalem from the gate of Ephraim unto the
corner gate ¹, four hundred cubits.
 ¹ So in 2 Kings xiv. 13. The text has, the gate that looketh.

23. the son of Jehoahaz] i.e. the son of Ahaziah, Jehoahaz and
Ahaziah being varying forms of the same name; compare xxi. 17
(note).

brake down the wall] Rather, made a breach (or breaches) in

the wall. The same verb is used in Nehemiah i. 3 (“broken down”)
and Nehemiah iv. 7 (“the breaches”).

the gate of Ephraim] Its precise position is not known, but it was
no doubt in the north or north-west wall of the city, on the road to
Ephraim. Compare Nehemiah viii. 16.

the corner gate] Hebrew text doubtful, but LXX. ἕως πύλης γωνίας.
Compare xxvi. 9; Jeremiah xxxi. 38; Zechariah xiv. 10. Most probably
this gate also was near the north-west angle of the walls, but nothing
certain is known of its position.

four hundred cubits] About 600 feet according to the ancient

cubit, and 700 according to the later standard; compare iii. 3 (note).

²⁴And he took all the gold and silver, and all

the vessels that were found in the house of
God with Obed-edom, and the treasures of the
king’s house, the hostages also, and returned
to Samaria.
24. And he took] The verb is missing in Chronicles, and is
supplied from Kings.

with Obed-edom] i.e. with the family of Obed-edom which (1

Chronicles xxvi. 4‒8, 15) served as doorkeepers in the House of
God. The words are an addition of the Chronicler.
 25‒28 (= 2 Kings xiv. 17‒20).
The End of Amaziah.

²⁵And Amaziah the son of Joash king of

Judah lived after the death of Joash son of
Jehoahaz king of Israel fifteen years. ²⁶Now
the rest of the acts of Amaziah, first and last,
behold, are they not written in the book of the
kings of Judah and Israel? ²⁷Now from the
time that Amaziah did turn away from
following the Lord they made a conspiracy
against him in Jerusalem; and he fled to
Lachish: but they sent after him to Lachish,
and slew him there.
27. from the time] The Chronicler characteristically connects the
conspiracy with Amaziah’s apostasy; in Kings the only fact of the
conspiracy is stated.

a conspiracy] Athaliah, Joash, Amaziah each fell one after the

other before a conspiracy. Jehoiada’s example had far-reaching
results.

to Lachish] Perhaps he was trying to reach Egypt.

²⁸And they brought him upon horses, and

buried him with his fathers in the city of
Judah ¹.
¹ In 2 Kings xiv. 20, the city of David.
 28. upon horses] Render, upon the horses; i.e. upon the horses
of some of his pursuers.

the city of Judah] Read, with the margin, the Versions and 2
Kings, the city of David.

Chapter XXVI.
1‒4 (= 2 Kings xiv. 21, 22, xv. 2, 3).
Uzziah’s Reign.

¹And all the people of Judah took Uzziah ¹,

who was sixteen years old, and made him
king in the room of his father Amaziah.
¹ In 2 Kings xiv. 21, Azariah.

1. all the people of Judah] Popular choice does not seem to have
determined the succession to the throne, except when the reigning
king had perished by a violent or untimely death, compare xxii. 1.

Uzziah] Called “Azariah” in 1 Chronicles iii. 12 and in 2 Kings

(eight times), but “Uzziah” in 2 Kings xv. 13, 32, 34; Isaiah i. 1, vi. 1;
Hosea i. 1; Amos i. 1; Zechariah xiv. 5. The two forms of the name
when written in Hebrew consonants closely resemble each other;
moreover the meanings of the two are similar, “Jah is my strength”
and “Jah hath given help.” Perhaps the king bore both names;
compare “Abram” and “Abraham”—“Eliakim” and “Jehoiakim” (xxxvi.
4).

²He built Eloth, and restored it to Judah, after

that the king slept with his fathers.
 2. Eloth] So spelt in viii. 17 (= 1 Kings ix. 26), but “Elath” in
Deuteronomy ii. 8; 2 Kings xiv. 22. In 2 Kings xvi. 6 the two forms are
found side by side in one verse.

after that the king, etc.] The meaning seems to be it was after
king Amaziah slept with his fathers that Uzziah his son restored
Elath to Judah; and it is a natural inference that Uzziah was ruling in
Jerusalem for some while before the death of Amaziah at Lachish
left him sole and undisputed king. A considerable time may have
elapsed between Amaziah’s flight and his capture as related in xxv.
27. Yet this is not very likely, and from the position of the present
verse in Kings it would seem as though the statement in its original
context should be interpreted thus: “he, Amaziah, built Eloth,” etc.;
and the king referred to in the clause “after that the king slept with
his fathers” is probably Jeroboam king of Israel (so Barnes on 2
Kings xiv. 22).

³Sixteen years old was Uzziah when he began

to reign; and he reigned fifty and two years in
Jerusalem: and his mother’s name was
Jechiliah of Jerusalem.
3. Jechiliah] so the Kethīb; the Ḳerī Jecoliah agrees with the
parallel passage of Kings.

⁴And he did that which was right in the eyes of

the Lord, according to all that his father
Amaziah had done.
4. his father Amaziah] This verse suits its original context in
Kings, for Kings records nothing against Amaziah; it is out of place in
Chronicles, for according to xxv. 14 Amaziah was an idolater.

5‒10 (not in Kings).

The Prosperity of Uzziah.
 5‒10. It is probable that the Chronicler had old and genuine
tradition to rely on for the account which he here gives of Uzziah’s
prosperity—his wars against neighbouring tribes (verses 6‒8), and
his building activity (verses 8‒10). Doubtless in the earlier years of
Uzziah’s reign Judah was still suffering from the effects of the defeat
inflicted by Joash of Israel. But the general accuracy of the picture of
the reign is assured by such facts as (1) the stout resistance offered
by Jerusalem to the Assyrians in Hezekiah’s time as contrasted with
its capture by the Israelites in Amaziah’s reign (xxv. 23); (2) the
frequency of metaphors from building implements and materials in
the pages of the prophets of this period (e.g. Amos vii. 7 ff.); (3) the
commercial activity and luxury of Jerusalem in the reign of Uzziah’s
successor Ahaz—witness the writings of Isaiah, passim.

⁵And he set himself to seek God in the days of

Zechariah, who had understanding ¹ in the
vision ² of God: and as long as he sought the
Lord, God made him to prosper.
¹ Or, gave instruction.

² Hebrew the seeing. Many ancient authorities have, the fear.

5. Zechariah] Nothing is known (apart from this passage) of this

Zechariah.

who had understanding] margin, “who gave instruction Hebrew

mēbhīn, a word applied to a leader of song (1 Chronicles xv. 22,
“skilful”; 1 Chronicles xxv. 7, “cunning”; 1 Chronicles xxv. verse 8,
“teacher”).

in the vision of God] Read, in the fear of God (so LXX., Targum
Peshitṭa), making a slight correction of the Hebrew text.
 ⁶And he went forth and warred against the
Philistines, and brake down the wall of Gath,
and the wall of Jabneh, and the wall of
Ashdod; and he built cities in the country of
Ashdod, and among the Philistines.
6. the Philistines] Compare xvii. 11, xxi. 16, xxviii. 18; 2 Kings
xviii. 8; 1 Maccabees v. 66‒68, xiv. 34.

brake down the wall] See note on xxv. 23.

Jabneh] Mentioned only here in the Old Testament, but probably

to be identified with “Jabneel” (Joshua xv. 11). At a later date it was
called “Jamnia” (2 Maccabees xii. 8), and, after the fall of Jerusalem
in 70 a.d., it became for a while the chief centre of Jewish intellectual
and religious activities. Its ruins are to be seen about 10 miles south
of Jaffa (Joppa) on the coast. The modern Yebna is a few miles
inland. Bädeker, Palestine⁵, p. 122.

Ashdod] compare 1 Samuel v. 1 ff.; Isaiah xx. 1; Zephaniah ii. 4;

Nehemiah iv. 7, xxiii. 23; Acts viii, 40 (Ἄζωτος). Ashdod (modern
Esdūd) was situated between Gaza and Joppa, some three miles
from the sea.

in the country of Ashdod] (literally “in Ashdod”). Perhaps the

name has been repeated through an early scribal error and we
should read simply “and built cities among the Philistines.”

⁷And God helped him against the Philistines,

and against the Arabians that dwelt in Gur-
baal, and the Meunim.
7. against the Philistines, and against the Arabians] “Conditions
in the comparatively small and half-desert land of Judah depended
essentially on its relations with the Edomite and Arabian tribes on the
south-east and with the Philistines on the west”: note how this comes
out in the traditions of the period as narrated in Chronicles
Jehoshaphat dominated both Philistines and Arabians (Edomites)
(xvii. 11); but Libnah (near Lachish) and Edom revolted successfully
against his son Jehoram (xxi. 10). After the reigns of Ahaziah and
Joash, Amaziah found himself able to assail Edom and gained a
great victory (xxv. 11, 12). Later in his reign Amaziah suffered a
crushing defeat at the hands of Joash of Israel, and it is reasonable
to suppose that Edom would seize the opportunity to reassert its
independence, though Chronicles is silent on the point. It is therefore
in harmony with the sequence of events as narrated by the
Chronicler, when in the present verse (compare verse 2) we are told
that Amaziah’s successor, Uzziah, reestablished the Judean power
over Edom, and that later, against Ahaz, Edom and the Philistine
cities gained the upper hand (xxviii. 17, 18).

Gur-baal] An unidentified place; a “Gur” is mentioned in 2 Kings

ix. 27. A slight correction of the Hebrew would give “in Gerar
(compare Genesis xx. 1) and against the Meunim.”

Meunim] compare xx. 1 (note).

⁸And the Ammonites gave gifts to Uzziah: and

his name spread abroad even to the entering
in of Egypt; for he waxed exceeding strong.
8. gave gifts] i.e. tribute. Compare 1 Chronicles xviii. 2 (note).

⁹Moreover Uzziah built towers in Jerusalem at

the corner gate, and at the valley gate, and at
the turning of the wall, and fortified them.
9. towers in Jerusalem, etc.] The Chronicler is evidently fond of
recording such traditions; compare xxxii. 30, xxxiii. 14; and the
Introduction § 7, p. xlviii.
 the corner gate] At the north-west corner of the walls. Compare
xxv. 23 (note).

the valley gate] Nehemiah ii. 13, iii. 13. Probably near the south-
west corner of the walls.

the turning of the wall] Mentioned Nehemiah iii. 19, 24. See G. A.
Smith, Jerusalem, II. 120.

¹⁰And he built towers in the wilderness, and

hewed out many cisterns, for he had much
cattle; in the lowland also, and in the plain ¹:
and he had husbandmen and vinedressers in
the mountains and in the fruitful fields ²; for he
loved husbandry.
¹ Or, table land. ² Or, Carmel See 1 Samuel xxv. 2.

10. the wilderness] i.e. the southern pasture land of Judah.

Compare Psalms lxv. 12. Fortified towers have always proved
effective for controlling the Bedouin and keeping the desert roads
open.

in the lowland also, and in the plain] For the “lowland” (Hebrew
Shephēlah) see i. 15 (note). The “plain” (margin table land; Hebrew
Mishōr) is the name of the high pasture lands east of Jordan;
apparently the part occupied by the Ammonites whom Uzziah had
subdued is meant here. (For a different view see Smith, Jerusalem,
II. 119, note.)

11‒15 (no parallel in Kings).

Uzziah’s Army.

¹¹Moreover Uzziah had an army of fighting

men, that went out to war by bands, according
 to the number of their reckoning made by Jeiel
the scribe and Maaseiah the officer, under the
hand of Hananiah, one of the king’s captains.
¹²The whole number of the heads of fathers’
houses, even the mighty men of valour, was
two thousand and six hundred. ¹³And under
their hand was a trained army ¹, three hundred
thousand and seven thousand and five
hundred, that made war with mighty power, to
help the king against the enemy.
¹ Or, the power of an army.

13. three hundred thousand and seven thousand and five

hundred] Compare xxv. 5 (Amaziah’s army), and the notes on xiv. 8
and xvii. 14 (the forces of Asa and of Jehoshaphat).

¹⁴And Uzziah prepared for them, even for all

the host, shields, and spears, and helmets,
and coats of mail, and bows, and stones for
slinging.
14. stones for slinging] Such stones needed to be carefully
chosen, for they had to be smooth and of a suitable size, compare 1
Samuel xvii. 40. Bows and slings appear to have been favourite
weapons in Benjamin, compare 1 Chronicles xii. 2; Judges xx. 16.

¹⁵And he made in Jerusalem engines,

invented by cunning men, to be on the towers
and upon the battlements ¹, to shoot arrows
and great stones withal. And his name spread
 far abroad; for he was marvellously helped, till
he was strong.
¹ Or, corner towers.

15. engines] Doubtless contrivances similar to the Roman

catapulta and balista. It is questionable whether such engines of war
were really in use as early as the time of Uzziah, at least among the
Israelites (see Smith, Jerusalem, ii. 121, 122; and the Encyclopedia
Biblia s.v. siege, especially col. 4510). The next reference to similar
instruments of war is in 1 Maccabees vi. 51, 52.

helped] compare verse 7.

16‒20 (not in Kings).

Uzziah’s Presumption.

16‒20. Uzziah died from leprosy, as is related in verses 21‒23 (=

2 Kings xv. 5‒7). That terrible disease was always regarded as a
manifestation of Divine anger against the sufferer (compare
Numbers xii. 9 ff.; 2 Kings v. 27), but no special cause is assigned in
Kings why the disaster befell Uzziah. In the present verses an
adequate reason is brought forward—Uzziah, blinded by the pride of
his success, infringed the privileges of the priesthood and was guilty
of sacrilege. The motive for some such tale is so strong and the
actual sin alleged so akin to the Chronicler’s prejudices that it may
well be that the tale originated with him or his immediate circle. Yet it
is possible that there may be behind the present form of the tale a
valid tradition of a dispute at this period between the hierarchy and
the authority of the king.

¹⁶But when he was strong, his heart was lifted

up so that he did corruptly ¹, and he trespassed
against the Lord his God; for he went into the
 temple of the Lord to burn incense upon the
altar of incense.
¹ Or, to his destruction.

16. did corruptly] Compare xxvii. 2.

he trespassed] compare xii. 2; Joshua vii. 1, xxii. 16. The Hebrew

word implies presumptuous dealing with holy things.

the altar of incense] Compare Exodus xxx. 1‒10. Not only the
altar, but the incense itself was “most holy”; Exodus xxx. verses 34‒
38.

¹⁷And Azariah the priest went in after him, and

with him fourscore priests of the Lord, that
were valiant men:
17. Azariah the priest] i.e. the high-priest (verse 20). He cannot
be identified with any priest in the list given 1 Chronicles vi. 4‒15 (v.
30‒41, Hebrew).

¹⁸and they withstood Uzziah the king, and said

unto him, It pertaineth not unto thee, Uzziah,
to burn incense unto the Lord, but to the
priests the sons of Aaron, that are
consecrated to burn incense: go out of the
sanctuary; for thou hast trespassed; neither
shall it be for thine honour from the Lord God.
¹⁹Then Uzziah was wroth; and he had a
censer in his hand to burn incense; and while
he was wroth with the priests, the leprosy
 brake forth ¹ in his forehead before the priests
in the house of the Lord, beside the altar of
incense.
¹ Hebrew rose (as the sun).

18. the priests the sons of Aaron] Compare xiii. 10, 11 and
Numbers xvi. 40.

neither shall it be for thine honour] A euphemism covering a

threat of danger and disgrace.

²⁰And Azariah the chief priest, and all the

priests, looked upon him, and, behold, he was
leprous in his forehead, and they thrust him
out quickly from thence; yea, himself hasted
also to go out, because the Lord had smitten
him.
20. the Lord had smitten him] So 2 Kings xv. 5.

21‒23 (= 2 Kings xv. 5‒7).

The End of Uzziah.

²¹And Uzziah the king was a leper unto the

day of his death, and dwelt in a several
house ¹, being a leper; for he was cut off from
the house of the Lord: and Jotham his son
was over the king’s house, judging the people
of the land.
 ¹ Or, lazar house.

21. a several house] i.e. separate, special; compare Numbers

xxviii. 13; Matthew xxv. 15. The same Hebrew word is used in
Psalms lxxxviii. 5, “free (Revised Version ‘cast off’) among the dead.”

cut off] The same Hebrew word is translated in the same way in
Isaiah liii. 8.

²²Now the rest of the acts of Uzziah, first and

last, did Isaiah the prophet, the son of Amoz,
write.
22. did Isaiah ... write] This statement is not in Kings. Uzziah is
mentioned in Isaiah vi. 1, and this fact may be all that lies behind the
present statement. It is utterly improbable that the reference is to
some writing of Isaiah which has not been preserved. Possibly some
section of the midrashic Book of the Kings of Judah and Israel is
meant, presuming that such a work was known to the Chronicler
actually or by tradition (see Introduction § 5, pp. xxxii, xxxvi).

²³So Uzziah slept with his fathers; and they

buried him with his fathers in the field of burial
which belonged to the kings; for they said, He
is a leper: and Jotham his son reigned in his
stead.
23. the field of burial] i.e. not actually in the tombs of the kings,
lest they should be defiled, but in ground adjoining the royal tombs.
Kings has simply “in the city of David.” Compare xxi. 20, xxiv. 25,
xxviii. 27.
 Chapter XXVII.
1‒6 (compare 2 Kings xv. 32‒35).
Jotham Succeeds.

¹Jotham was twenty and five years old

when he began to reign; and he reigned
sixteen years in Jerusalem: and his mother’s
name was Jerushah the daughter of Zadok.
1. he reigned sixteen years] The years during which he acted as
regent in place of his father (see above xxvi. 21) are included in the
sixteen. Jotham’s independent reign was probably very brief.

²And he did that which was right in the eyes of

the Lord, according to all that his father
Uzziah had done: howbeit he entered not into
the temple of the Lord. And the people did
yet corruptly.
2. according to all that ... howbeit he entered not into the temple
of the Lord] i.e. he imitated Uzziah in all his virtues, but not in his sin
against the ritual of the Temple (xxvi. 16 ff.). The clause howbeit,
etc., is not in Kings, since Kings makes no reference to Uzziah’s
transgression.

did yet corruptly] In Kings, “Howbeit the high places were not
taken away; the people still sacrificed and burned incense in the high
places.”
 ³He built the upper gate of the house of the
Lord, and on the wall of Ophel he built much.
3. the upper gate] Compare the note on xxiii. 20.

and on the wall of Ophel he built much] The statement is made

only in Chronicles Like similar notices of building activity, etc.—a
subject of great interest to the Chronicler—it may possibly have
some basis in fact; compare xxvi. 9 f., xxxii. 30, xxxiii. 14.

Ophel] compare xxxiii. 14; Nehemiah iii. 26, 27. It was a southern
spur of the Temple Hill. Bädeker, Palestine⁵, p. 31; and Smith,
Jerusalem, i. 152 ff.

⁴Moreover he built cities in the hill country of

Judah, and in the forests he built castles and
towers.
4. castles] compare xvii. 12 (note).

⁵He fought also with the king of the children of

Ammon, and prevailed against them. And the
children of Ammon gave him the same year
an hundred talents of silver, and ten thousand
measures ¹ of wheat, and ten thousand of
barley. So much did the children of Ammon
render unto him, in the second year also, and
in the third.
¹ Hebrew cors.

5. the children of Ammon] Compare xx. 1 ff., xxvi. 8.

 an hundred talents of silver] Compare 2 Kings xxiii. 33.

measures] Hebrew kōrīm. A kōr (= a ḥōmer, Ezekiel xlv. 14,

Revised Version) was a dry measure holding about 11 bushels.

⁶So Jotham became mighty, because he

ordered his ways before the Lord his God.
6. became mighty] The same Hebrew word as in i. 1 (see note).

7‒9 (= 2 Kings xv. 36‒38).

The Summary of Jotham’s Reign.

⁷Now the rest of the acts of Jotham, and all his

wars, and his ways, behold, they are written in
the book of the kings of Israel and Judah. ⁸He
was five and twenty years old when he began
to reign, and reigned sixteen years in
Jerusalem. ⁹And Jotham slept with his fathers,
and they buried him in the city of David: and
Ahaz his son reigned in his stead.
7. all his wars] Only a war with Ammon is mentioned above, but
according to 2 Kings xv. 37 the Syro-Ephraimite war also began in
Jotham’s reign. The notices in Kings and Chronicles may be
regarded as supplementary. Ammon was a natural ally of the
Syrians, and perhaps the wording of verse 5 (end) hints that after the
third year Ammon was able to refuse to pay tribute. The information
of Chronicles is therefore plausible; but it is curious that Chronicles
preserves the one incident and Kings the other. The point is highly
significant. Not only does it illustrate very forcibly the comparative
independence of the Chronicler’s narrative, which is so marked a
feature in these later reigns; but also it adds to the evidence in
favour of the view that the Chronicler had traditions before him other